Acute chest syndrome

Etiology

  • Rib infarct causing splinting & atelectasis
  • Pulmonary fat embolism
  • Infection (mycoplasma, chlamydia, viral)

Clinical Sx

  • Pleuritic chest pain
  • Fever
  • Cough
  • Tachypnea
  • Hypoxemia

Lab diagnosis

  • Worsening anemia, elevated HBSS%
  • Infiltrate on CXR

Treatment

  • IV hydration (~1.5 x maintenance)
  • Supplemental O2 (sats > 92%)
  • Incentive spirometry
  • Albuterol
  • Consider early BiPAP
  • Antibiotics for presumed infection
  • Pain meds
  • RBC transfusion
    • Simple transfusion (Hgb > 10) 
  • Exchange transfusion- multiple lobes involved, rapidly progressing, or worsening hypoxemia

Superior vena cava syndrome

  • Results from compression or obstruction of the SVC
  • Etiology: Lymphomas, Extrinsic compression,
  • Intravascular thrombosis, Histoplasmosis
  • Sx: Facial engorgement, headache, plethora, cyanotic facies, cough, dyspnea, orthopnea, wheezes. May also see pleural or pericardial effusions.
  • Pts do not tolerate supine position!
  • Do not sedate patients with suspected mediastinal mass without anesthesia involvement!!! Pts are at risk of sudden cardiorespiratory collapse from tracheal obstruction.

Veno-occlusive disease

  • Triad of hepatomegaly, weight gain, jaundice
  • Usually occurs 7-20 days post transplant
  • Findings: Fluid retention, hyperbilirubinemia, portal hypertension, clotting abnormalities
  • Ultrasound usually for diagnosis, consider liver biopsy
  • Tx: Ursodiol and Lovenox.  Other considerations are prostaglandins and defibrotide

Tumor lysis syndrome

  • Rapid destruction of tumor cells overwhelming usual metabolic pathways
  • Seen after chemotherapy, steroids, hormones, radiation
  • Hyperuricemia, hyperkalemia, hyperphosphatemia.
  • Symptomatic hypocalcemia. (precipitant of Ca phos)
  • Risk factors for ARF are primary tumor infiltrates, obstruction of urine flow, pre-existing renal pathology, & dehydration.
  • Risk factors for TLS are Burkitt's lymphoma / leukemia, acute leukemias, non-Hodgkin’s lymphoma, tumors w/ rapid growth rate and large tumor  burdens.
  • Tx: D5 ¼ NS + 50-100 meq/L
    • Na Bicarb @ 2X maint
    • Keep urine pH 7 – 7.5
    • Rasburicase or Allopurinol (Discuss w/ Heme-onc) 

Respiratory failure post transplant

Early recovery period – Bacterial / fungal infections, sepsis, mucositis and upper airway obstruction, acute pulmonary edema, pulmonary vascular disease (diffuse alveolar hemorrhage), idiopathic pulmonary syndrome

Mid recovery – Cytomegalovirus pneumonitis (primary or reactivation), opportunistic infections (PCP), Interstitial pneumonitis

Late recovery – Common infections, CMV reactivation, Adenovirus, Chronic graft-versus-host, Bronchiolitis obliterans